Fill and Sign the Doctor Estimate of Physical Capacities Washington Form

           Yes No Yes No                                           Yes No            0 1/ 2 1 2 3 4 5 6 7 8 0 1/ 2 1 2 3 4 5 6 7 8 0 1/ 2 1 2 3 4 5 6 7 8 0 1/ 2 1 2 3 4 5 6 7 8 0 1/ 2 1 2 3 4 5 6 7 8 0 1/ 2 1 2 3 4 5 6 7 8 Department of Labor and Industries Claims Section DOCTOR'S ESTIMATE OF PO Box 44291 Olympia WA 98504- 4291 PHYSICAL CAPACITIES Name of Claimant Claim Number Important: Please complete the following items based on your clinical evaluation of the claimant and other testing results. Any item that you do not believe you can answer should be marked N/A. Percentages refer to a workday. I. In an 8 hour workday, worker can: (Circle full capacity for each activity)Total at one time (hours) A) Sit Total during entire 8 hour day (hours)A) Sit B) Stand B) Stand C) Walk C) Walk II Worker can lift: (Address any restrictions in lifting from the floor or to overhead in ''Remarks '' section) III. Worker can carry: Never Seldom Occasionally Frequently Continuously (0- 1-/.) (2- 33%) (34- 66%) (67 - 100%) Lift Carry Lift Carry Lift Carry Lift Carry Lift Carry A) Up to 5 lbs B) 6 - 10 lbs C) 11 - 20 lbs D) 21 - 25 lbs E) 26 - 50 lbs F) 51 - 100 lbs IV. Worker can use hands for repetitive tasks such as- Simple grasping Pushing & pulling Fine manipulating A) Right Yes No Yes No Yes No B) Left Ye s No Yes No Yes No V. Worker can use feet for repetitive movements as in operating foot controls: Right Lef t Not at all Seldom Occasionally Frequently Continuously VI. Worker is able to: (0-1%) (2-33%) (34- 66%) (67 - 100%) A) BendB) Squat C) Kneel D) Crawl E) Climb F) Reach above shoulder level VII.. Restriction on activities involving: Yes No If ''Yes,'' explain: A) Unprotected heights B) Being around moving machinery Q Exposure to marked changes in temp & humidity D) Driving automotive equipment E) Exposure to dust, fumes and gasses (Restrictions)- Remarks (on above, on other functional limitations): F242-022-000 (PDF) Dr's est of physical capacities 8-98 Date Signature of Physician If a performance-based physical capabilities evaluation is requested, may the worker be tested to tolerance? If not, what are the restrictions?